Medicare Advantage Plans & Other Medicare Plans

Medicare Advantage Plans & Other Medicare Plans

with edits by Illinois SHIP - Module 11

04/21/23 Medicare Advantage 204/21/23

Medicare Choices

• Original Medicare

• Medicare Advantage (MA) Plans

• Medicare drug plans– Medicare Prescription Drug Plans– Medicare Advantage Plans with prescription

drug coverage

04/21/23 Medicare Advantage 3

Part A & B

Some will include Part D

Part – B

Part – A

Part – D or Secondary

MedSup

or

Secondary

Ways to receive Medicare

Original MedicareMedicare Advantage

(HMO, PPO, etc)


• Health plan options approved by Medicare

• Run by private insurance companies

• Part of the Medicare program– Sometimes called “Part C” or Medicare Health Plans

• Provides Medicare-covered benefits– May cover extra benefits, e.g.; vision or dental

What Are Medicare Advantage (MA) Plans?


How MA Plans Work• You are still in the Medicare program• You receive Medicare-covered services through the plan

– All Part A and Part B covered services– Some plans may provide additional benefits

• Most plans include prescription drug coverage• You may need to use network doctors or hospitals• MA plans may be different than Original Medicare

– Benefits and cost-sharing

• If the plan leaves Medicare– You can join another MA plan– You can return to Original Medicare

• You still have Medicare rights and protections


Types of Medicare Advantage Plans

• Medicare Health Maintenance Organization (HMO)

• Medicare Preferred Provider Organization (PPO)

• Medicare Private Fee-for-Service (PFFS)

• Medicare Special Needs Plan (SNP)


Medicare HMO Plans• Generally must get care and services from plan’s network

– Use doctors and hospitals that belong to the plan

– May need to choose primary care doctor

– Usually need a referral to see a specialist

– Doctors can join or leave

• Copayment amounts set by plan

• May have to pay in full for care outside plan’s network

– Covered if emergency or urgently needed care

• May include prescription drug coverage– If signing up for Part D, must take coverage with same plan

• Some plans may offer a Point-of-Service (POS) option– May allow you to get some services out-of-network– You may have to pay a higher cost share for these services


Medicare PPO Plans• Have the option to use network providers or out-of-network

providers that accepts Medicare• Don’t need referral to see specialist• Copayment and coinsurance amounts set by plan

– Will usually pay more for out-of-network care

• There are two types of PPO’s offered– Local PPOs

• Can service one county or multiple counties

– Regional PPOs • Coverage can be a region such as, an entire state or a multi-state

coverage area• Have annual limit on out-of-pocket costs

o Varies by plan

• May have higher deductible and/or premium than other PPOs

• May offer Medicare prescription drug coverage


Medicare PFFS Plans• Can see any Medicare-approved doctor

or hospital that accepts the plan– Can get services outside service area– Plan sets copayment amounts– For PFFS network rules see individual plan info

• If offered, can get Medicare prescription drug coverage

• If not offered, can join a stand-alone Medicare Prescription Drug Plan (PDP)


Changes in Access Requirements for PFFS Plans – By 2011

• Medicare PFFS – If two or more network-based MA Plans (such

as HMOs and PPOs) exist in a service area they must offer a network

• Employer PFFS – Must have contracts with networks of providers


Special Needs Plans (SNPs)

• Designed to provide– Focused care management– Special expertise of plan’s providers– Benefits tailored to enrollee conditions

• Must include prescription drug coverage


Special Needs Plans (continued)

• Three types of SNPs– Must limit membership to people

• With certain chronic or disabling conditionso Heart disease, diabetes, etc.

• Eligible for Medicare and Medicaid• In certain institutions (confined to a nursing home)

• Available in some areas– Visit www.medicare.gov– Call 1-800-Medicare


Who Can Join?

• Eligibility requirements– Live in plan’s service area– Entitled to Medicare Part A– Enrolled in Medicare Part B– Not have End-Stage Renal Disease (ESRD) at enrollment

• Some exceptions

• To join an MA plan, a person must also– Agree to provide the necessary information to the plan– Agree to follow the plan’s rules– Belong to only one Medicare Advantage plan at a time


When You Can Join or Switch MA Plans*

Initial Coverage Election Period

• 7 month period begins 3 months before the month you turn 65

–Includes the month you turn 65–Ends 3 months after the month you turn 65

Annual Election Period for 2010

• November 15 – December 31• Coverage begins January 1, 2011

*Plan must be allowing new members to join.


When you can Join or Switch MA Plans*

Annual Election Period for 2011 and After

October 15 – December 7 each yearCoverage begins Jan. 1 of following year

MA Open Enrollment Period

• Was January 1 – March 31 each year• Eliminated in 2011

Special Election Period

• Move from the plan service area –and cannot stay in the plan

• Plan leaves Medicare program• Other special situations

*Plan must be allowing new members to join.


When you can Join or Switch MA Plans

New in 2011Annual Disenrollment Period

• Can leave an MA plan and switch to Original Medicare

• Between January 1–February 14– Coverage begins the first of the month after

you switch • If you make this change you also may join

a Medicare Prescription Drug Plan to add drug coverage – Between January 1-February 14– Drug coverage begins the first of the month

after the plan gets enrollment form


MA Plan Cost

• Must still pay Part B premium– Some people may be eligible for state assistance

• Medicare Savings Program (MSP)

• May pay an additional monthly premium to plan

• You pay deductibles, coinsurance and copayments – Different from Original Medicare– Varies from plan to plan– Costs may be higher if you go out of network


Monthly Premiums- 2011

• Starting January 1, 2011 Part D monthly premiums may be higher based on income

– Includes PDP and MA-PD plans

• If income is above – $85,000 filing individual tax return– $170,000 filing a joint tax return

Additional monthly adjustments will be charged in addition to part D premiums

• SSA will be contacting those who have to pay higher premiums in November


Non-renewing MA plans Guaranteed Options

• Plan must send notification of non-renewal 90 days prior to last day of coverage

• Affected Members have a Special Enrollment Period-SEP • Can pick up a new MA plan

– October 1, 2010 to January 31, 2011– Effective dates of either

• January 1 or February 1, 2011 (depending on application date)

• If another MA plan is not selected– Beneficiary will be defaulted to Original Medicare on effective date

of termination• 63 days to join a PDP• 63 days for a guaranteed issue Medicare Supplement policies

A, B,C,F, K, L


Medicare Advantage Trial Right Special Election Period

• People who join an MA plan for the first time– When first eligible for Medicare at age 65 or – Leave Original Medicare and drop Medigap policy

• Can disenroll from MA plan during first 12 months– Join Original Medicare– Have guaranteed issue for Medigap policy


Comparing Plans

• Use on-line tool at www.Medicare.gov– Choose the “Health and Drug Plans” tab

• Compare, Review, and Enroll

• Make sure MA plan services your area• If seeking MA plan with drug coverage make

sure the plan has needed drugs in formulary• Call the plan or Visit their website


Rights in All Medicare Plans

• People with Medicare have certain guaranteed rights– To get the health care services they need

– To receive easy-to-understand information

– To have their personal medical information kept private

– Access to health care providers

– Know how doctors are paid

– Fair, efficient, and timely appeals process

– Fast appeals in certain health care settings


Appeals in MA

• Plan must say in writing how to appeal if– Will not pay for a service– Does not allow a service– Stops or reduces a course of treatment

• Can ask for fast (expedited) decision– Plan must decide within 72 hours

• See plan's membership materials– Include instructions on how to file an appeal or grievance


Required Notices

• After every – Adverse determination– Adverse appeal

• Include– Detailed explanation of why services denied– Information on next appeal level– Specific instructions

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Medicare Advantage Plans & Other Medicare Plans

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